Membership Application

Membership Application to Virtual Clubhouse
Due to the COVID-19 pandemic and the Shelter in Place our California Clubhouse facility is currently closed. Our community has created a Virtual Clubhouse where we continue with our services and provide virtual programming and social opportunities. Our purpose is to keep our community strong and available to continue connecting with one another and prevent isolation.

All participation is voluntary and at no cost to members.

When the Clubhouse facility opens its physical doors again, our Welcome Committee will connect with you by scheduling a one-on-one orientation to tour our facility and to finish paperwork needed for onsite membership.
Name:

First Name Last Name
Date Of Birth:

Month Day Year
Date
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail:
Phone Number:

Area Code Phone Number
How can we best contact you?
Primary Care Provider
The following can be contact information for your case manager, therapist, primary care provider.

All information will be kept confidential.
Agency:
Care Provider Name:

First Name Last Name
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Membership Self-Referral Information:
To be eligible for California Clubhouse programs, members need to live in San Mateo County*, be 18 years of age or older, and have a diagnosis of Schizophrenia Disorder, Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, Anxiety Disorder, PTSD or Depression.

All information will be kept confidential.

*If you do not reside in San Mateo County, connect with us via email or phone.
Mental Health Diagnosis

Schizophrenia Disorder Schizoaffective Disorder Bipolar Disorder Major Depressive Disorder Anxiety Disorder PTSD
Please confirm your age and county:

I am 18 years or older I reside in San Mateo County
Signature *

Clear
Signature Date:

Month Day Year
Date
Should be Empty:

Membership Application to Virtual Clubhouse

Primary Care Provider

Membership Self-Referral Information: